ucts for use by its members. Lisa Rieg, the infectious diseases pharmacist for the California division of the organization, discussed the process of forecasting vaccine requirements and emerging concerns regarding future vaccine purchases.

Kaiser subscribers receive all routine immunizations without any copayment or other additional charge, and coverage rates are more than 90 percent for many of the recommended vaccines. Kaiser also participates in clinical trials for new vaccines and in the Vaccine Safety Datalink project. An electronic database on immunization records alerts providers to immunizations that patients require and allows for production of quarterly reports on immunization coverage rates. The database also aids in appropriately allocating supplies of vaccines that are in short supply. Dr. Rieg noted that the southern California division of Kaiser Permanente has been slow to participate in VFC because of the administrative burdens associated with tracking eligible patients and the vaccine inventory. Another factor has been the inability to ensure that the VFC program will supply the vaccine products that Kaiser uses for all other members.

Forecasting vaccine requirements involves consideration of several factors. It is important to understand the disease a vaccine is directed against and the risk it poses to the population Kaiser serves. Also necessary is information about a vaccine’s efficacy and safety profile, as well as its cost effectiveness. Another consideration is whether a vaccine is or will be included in the recommended immunization schedule for children or adults. Estimates of the number of doses required depend on the number of children or adults who would receive a vaccine as part of a routine schedule (e.g., an annual birth cohort for most pediatric vaccines) and whether additional doses are needed for “catch-up” programs for a newly recommended vaccine or for special efforts to improve coverage.

Unanticipated factors can affect the accuracy of these forecasts. Accurately estimating the cost of a new vaccine has proved especially difficult, and most estimates have been too low. Slow acceptance of a new vaccine by providers or patients can result in lower usage, but interest spurred by clinical needs or publicity can increase demand. For example, publicity about the Lyme disease vaccine stimulated demand even though the disease risk is low in southern California. A patient education program was undertaken to inform members about appropriate uses of the vaccine.

Dr. Rieg indicated that, so far, the increase in vaccine costs has been minimal compared with the cost increases for other pharmaceuticals. Kaiser has benefited from its ability to negotiate lower prices for high-volume purchases and to establish long-term contracts. However, vaccine costs seem likely to increase more steeply in the future. Prices for new vaccines, like the pneumococcal conjugate vaccine, are proving to be much higher than expected. As purchasing contracts end, Kaiser has less



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